IntroductionSystemic anaplastic large-cell lymphoma (ALCL) is an aggressive peripheral T-cell lymphoma. There are 2 types of ALCL, classified as anaplastic lymphoma kinase (ALK)-positive (ALK ϩ ) or ALKnegative (ALK Ϫ ) depending on whether the receptor tyrosine kinase ALK is expressed. ALK is activated most frequently through the nonrandom t(2;5) chromosome translocation, resulting in the fusion of the nucleophosmin (NPM) gene from the 5q35 locus to the 2p23 region that encodes ALK. 1,2 ALK ϩ ALCLs are characterized by frequent extranodal colonization, particularly in the skin (reported in 20%-30% of cases), and this is associated with a negative prognosis. 1 The diagnosis of cutaneous dissemination in ALK ϩ ALCL is not always easy and, in some cases, the original histopathological classification is one of "non-malignant inflammatory disease." 3 Interestingly, an insect bite could be the trigger for cutaneous ALK ϩ lymphoma metastases. Our group reported 5 cases of systemic ALK ϩ ALCL in which skin lesions presented after an insect bite at the onset of the disease, postulating that bite-associated Ags could result in an influx of T lymphocytes, some of them bearing the t(2;5) translocation. 4 The subsequent release of cytokines leading to skin inflammation at the site of the bite could act as a "second hit" eliciting activation of T lymphocytes, which would then express the oncogenic NPM-ALK protein and undergo uncontrolled proliferation and transformation. 4 ALK ϩ ALCL patients also present with an inflammatory syndrome characterized by high fever, lymphadenopathy or neutrophilia, release of various circulating inflammatory chemokines such as IL-8, 5 and expression of skin-inflammatory biomarkers such as the alarmins heat-shock protein 90 (HSP90), HSP70, 6 S100A8, or A11. 7 Recent studies have highlighted a role for IL-8 in mediating cutaneous skin inflammation and human keratinocyte hyperplasia associated with acanthosis (thickening of the skin). 8 IL-8 secreted by hyperplasic keratinocytes increases T-lymphocyte migration into the skin across both the vascular endothelium and the subendothelial matrix. 9 The high-mobility-group box-1 (HMGB-1) alarmin, also called amphoterin, is a highly conserved component of eukaryotic nuclei. 10 Interestingly, it can also be released from necrotic and tumoral cells, where it is considered an inflammatory cytokine. T-and B-cell non-Hodgkin lymphoma cells express and release high levels of HMGB-1. 11 Its extracellular form binds to inflammatory receptors, such as the receptor for advanced glycation end products (RAGE) and TLR. 12,13 HMGB-1 has also been shown to regulate matrix metallopeptidase-9 (MMP-9) levels via NF-Brelated pathways. 14,15 In ALK ϩ ALCL, we have demonstrated that MMP-9 is required for NPM-ALK ϩ cell invasiveness. 16 Moreover, MMPs stimulate protease-activated receptors (PARs). 17 Activation of PAR-2 results in the production of various cytokines and chemokines by keratinocytes, 18 leading to epidermic inflammation via increased NF-B p65 phosphorylation an...